NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corporation)

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NEW YORK LIFE INSURANCE AND ANNUITY CORPORATION (A Delaware Corporation)

PARTIAL WITHDRAWAL/ PERIODIC PARTIAL WITHDRAWAL REQUEST FORM NYLIAC Single Premium Variable Universal Life, NYLIAC Variable Universal Life 2000,

NYLIAC Variable Universal Life, NYLIAC Survivorship Variable Universal Life, NYLIAC Variable Universal Life Provider, New York Life Survivorship Variable Universal Life Accumulator, New York Life Variable Universal life Accumulator, NYL Legacy Creator Single Premium Variable Universal Life

Date: Policy Number:

Policyowner(s) :

Insured(s):

Instructions: 1. 2. 3. 4.

5. 6.

If you wish to request a one-time Partial Withdrawal, complete Sections A and C through E. For Variable Universal Life Provider only, if you wish to set up or modify an automated Periodic Partial Withdrawal Arrangement, complete Sections B through E. Read the Important Income Tax Information on page 8. Date and sign page 7, Section F of this form and secure all other required signatures. If the policy is jointly owned and has another designee(s) who are authorized to request transactions on the policy, the signatures of all joint owners and designees are required. All signatories must provide their Tax Identification Number. If you have any questions, please contact one of our Customer Service Representatives toll-free at 1-800-598-2019. For online policy information and service, please visit our Virtual Service Center at www.newyorklife.com/vsc. If you are using the funds from this policy to purchase/fund another policy, please consider all aspects of the transaction before making a final decision to ensure that it is in your best interest. The withdrawal of these funds may affect the guaranteed and non-guaranteed values, including the face amount and surrender value of the policy from which the funds are being released.

Please read the prospectus for further details regarding Partial Withdrawals and Periodic Partial Withdrawals. Please Note: If New York Life receives this request and any required information is incomplete, this request will not be processed. We will notify you if your request is incomplete. If you resubmit the request, the transaction(s) will then be effective as of the date on which we receive this completed resubmission.

Variable products are distributed by NYLIFE Distributors LLC, Member FINRA/SIPC and offered through properly licensed registered representatives.

RETURN FORM TO: For Variable Life and Variable Annuity policies:

New York Life, Variable Products Service Center Madison Square Station, PO Box 922, New York, NY 10159

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SECTION A

PARTIAL WITHDRAWAL

PLEASE INDICATE THE AMOUNT YOU WISH TO WITHDRAW AND COMPLETE THE BALANCE OF THIS FORM. For SPVUL, VUL 2000, VUL, and SVUL, a fee not to exceed the lesser of $25 or 2% of the amount withdrawn is imposed for each withdrawal. The minimum amount that may be withdrawn is $500. For Variable Universal Life Provider and Legacy Creator SPVUL we may impose a fee, which will not exceed $25.00. The minimum amount that may be withdrawn is $100.00 for Provider; $500.00 for Legacy Creator SPVUL. I REQUEST A WITHDRAWAL AMOUNT OF: $ Please check 1 or 2: 1. (Gross) I understand that I may receive less than this amount if I elect to have taxes withheld and/or a surrender charge applies.

2. (Net) I wish to receive the full amount specified above. I understand that the amount deducted from my policy may be greater if I elect to have taxes withheld and/or a surrender charge applies.

If this partial withdrawal includes monies to be withdrawn for the purposes of paying a premium for another New York Life or a Long Term Care product, please indicate the policy number and payment type. Please Note: Loan Repayments are not eligible for Long Term Care products. The partial withdrawal will be used to pay the premiums on the following policy number: __________________________________________________________ Premium Payment Type: Scheduled Premium Payment

SECTION B

Additional Premium Payment

Loan Repayment

PERIODIC PARTIAL WITHDRAWAL (PPW) ARRANGEMENT

FOR VARIABLE UNIVERSAL LIFE PROVIDER ONLY: Please complete this section if you wish to receive Periodic Partial Withdrawals on a regular schedule. Only one Periodic Partial Withdrawal arrangement may exist for each policy. If a new election form is received it will cancel any previous election form. You may not elect to receive Periodic Partial Withdrawals if you are currently making scheduled deposits to your policy via automatic deposits from your bank. Except as provided below, Periodic Partial Withdrawals will continue until notification to terminate them is received by NYLIAC. Please Note: Periodic Partial Withdrawal arrangements can not be selected within the first year of your policy. The base coverage amount on the policy must be maintained at a minimum of $100,000. For the periodic partial withdrawal arrangement to continue as scheduled, the Cash Surrender Value must be maintained at a $2,000 minimum and must be sufficient to cover the policy’s monthly charges. If the Cash Surrender Value falls below this minimum and/or is insufficient to cover the monthly charges, this option will be suspended. If the Cash Surrender Value then reaches the minimum required and/or the monthly charges have been satisfied, the periodic partial withdrawal arrangement will automatically restart on the next scheduled date. If your Cash Surrender Value is not at the required minimum and/or is insufficient to cover the policy’s monthly charges at any time, we will notify you. At the time of the next scheduled withdrawal, if the amount of the periodic partial withdrawal combined with the total gross amount of all withdrawals taken from your policy exceeds the total premiums paid since your policy’s inception, we will not process the withdrawal. The periodic partial withdrawal arrangement will no longer be in effect on your policy and we will notify you. However, you may still request nonscheduled partial withdrawals and/or loans. To process a periodic partial withdrawal arrangement, NYLIAC must receive this form at least five business days before the date the withdrawals are to begin. The withdrawals will be effective on the day of the month you specify. If the day of the month specified is within five days of NYLIAC’s receipt of this form, then the withdrawals will begin in the following month.

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SECTION B

PERIODIC PARTIAL WITHDRAWAL (PPW) ARRANGEMENT (Continued)

I ELECT TO RECEIVE SCHEDULED PAYMENTS OF: A Specified Amount (Minimum $100) $___________________. (The specified amount will be withdrawn for each payment. We may impose a fee which will not exceed $25.00. A surrender charge may apply.) Choose one option: 1. (Gross) I understand that I may receive less than this amount if I elect to have taxes withheld and/or a surrender charge applies. 2. (Net) I wish to receive the full amount specified above. I understand that the amount deducted from my policy may be greater if I elect to have taxes withheld and/or a surrender charge applies. If any of these periodic partial withdrawal options includes monies to be withdrawn for the purposes of paying a premium for another New York Life or a Long Term Care product, please indicate the policy number: The periodic partial withdrawal will be used to pay the premiums on the following policy number: ___________________________________________________________

INDICATE FREQUENCY OF PARTIAL WITHDRAWALS: Monthly

Quarterly

Semi-Annually

Annually

PLEASE INDICATE THE DATE FOR THE FIRST PAYMENT TO BE WITHDRAWN FROM YOUR POLICY: Payment dates may not be the 29th, 30th, or 31st of a month:_____________________________________________ Month Day Year

SECTION C ELECTRONIC FUNDS TRANSFER (EFT) To have your Partial Withdrawal/ Periodic Partial Withdrawal payment(s) sent directly to your bank account, via Electronic Funds Transfer (EFT), please provide the following information: If we are unable to send your payment(s) via EFT to the bank account provided, we will send a check to the address of record or the current address provided on page 6: Name of Financial Institution and Branch Name (if any)

____________________________________________________________________

Address of Financial Institution ____________________________________________________________________ ____________________________________________________________________ Routing Number of Financial Institution ______________________________________________________________ Account Number for Deposit of Payments____________________________________________________________ Accountholder’s Name____________________________________________________________________________ Please Check One:

Checking Account

Saving Account

If the payment(s) are to be deposited into a Checking Account, please attach a voided check. If the payment(s) are to be deposited into a Savings Account, please provide a deposit slip that confirms the account and routing numbers.

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SECTION C

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ELECTRONIC FUNDS TRANSFER (EFT) (Continued)

For Variable Universal Life Provider only: If the day you have chosen for your Periodic Partial Withdrawal payments falls on any day which is not a business day (e.g., a weekend or holiday) your payment shall be made on the following business day. The unit value for each payment will be equal to the unit value for the respective Allocation Alternative on the day the payment is made. Note: Your financial Institution must be a member of the Automatic Clearing House (ACH). Please check with your Financial Institution.

SECTION D

ALLOCATION ALTERNATIVES

PLEASE INDICATE THE AMOUNT TO BE WITHDRAWN FROM THE FOLLOWING INVESTMENT DIVISION(S) AND/OR FIXED ACCOUNT. If no indication is given, payment(s) will be taken on a proportional basis, based on the allocation of the cash value in the Allocation Alternatives at the time of the withdrawal. Risk classifications are provided in the parenthesis after the Investment Division. Risk classifications are determined on the basis of the Lipper Category assigned to the Investment Division by Lipper Analytics as of December 31, 2008. Lipper is a widely used independent research firm, which ranks mutual funds and other investment companies by overall performance, investment objectives and assets. FOR VARIABLE UNIVERSAL LIFE PROVIDER PERIODIC PARTIAL WITHDRAWALS ONLY: Your periodic partial withdrawal arrangement will be suspended if there is insufficient cash value in any of the investment divisions you have selected. If the cash value in the investment division(s) then reaches the minimum required, the periodic partial withdrawal will automatically restart on the next scheduled date. You may change your allocation alternatives for your periodic partial withdrawal at any time. NAME NUMBER NAME NUMBER Fixed Account

101

Dollar Cost Averaging Plus (DCA Plus) Account

$ $

Dollar Cost Averaging Extra Account MainStay VP Balanced – Initial Class (Moderate) MainStay VP Bond – Initial Class (Moderate) MainStay VP Capital Appreciation – Initial Class (High)

305

$

145

$

107

$

104

$

MainStay VP Cash Management (Low) MainStay VP Common Stock – Initial Class (High) MainStay VP Conservative Allocation – Initial Class (Moderate) MainStay VP Convertible – Initial Class (Moderate) MainStay VP Floating Rate – Initial Class (Moderate) MainStay VP Government – Initial Class (Moderate) MainStay VP Growth Allocation – Initial Class (High) MainStay VP High Yield Corporate Bond – Initial Class (Moderate) MainStay VP ICAP Select Equity – Initial Class (Moderate)

102

$

108

$

148

$

119

$

144

$

103

$

151

$

110 121

MainStay VP Moderate Growth Allocation – Initial Class (Moderate) MainStay VP S&P 500 Index – Initial Class (High) MainStay VP Small Cap Growth – Initial Class (Highest) MainStay VP Total Return – Initial Class (Moderate) AIM V.I. International Growth Fund – Series l Shares (High) Alger American SmallCap Growth Portfolio– Class O Shares (Highest)* AllianceBernstein VPS Small/MidCap Value Portfolio – Class A Shares (High) CVS Calvert Social Balanced Portfolio (Moderate) Dreyfus IP Technology Growth – Initial Shares (Highest) DWS Dreman Small Mid Cap Value – Class A Shares (High)

150

$

105

$

135

$

106

$

154

$

116

$

153

$

112

$

138

$

153

$

115

$

113

$

114

$

$

Fidelity® VIP Contrafund® - Initial Class (High) Fidelity® VIP Equity-Income – Initial Class (Moderate) Janus Aspen Balanced Portfolio – Institutional Shares (Moderate) Janus Aspen Worldwide Portfolio – Institutional Shares (High)**

117

$

$

MFS® Utilities Series – Initial Class (Moderate)

208

$

Allocation Alternative Listing Continues on the Next Page

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NAME MainStay VP Income and Growth – Initial Class (High) MainStay VP International Equity – Initial Class (High) MainStay VP Large Cap Growth – Initial Class (High) MainStay VP Mid Cap Core – Initial Class (High) MainStay VP Mid Cap Growth – Initial Class (High) MainStay VP Mid Cap Value – Initial Class (High) MainStay VP Moderate Allocation – Initial Class (Moderate)

NUMBER

NAME

120

$

109

$

122

$

136

$

137

$

134

$

149

$

NUMBER

Royce Micro-Cap Portfolio – Investment Class (High) Royce Small-Cap Portfolio – Investment Class (High) T. Rowe Price Equity Income Portfolio (Moderate) Van Eck Worldwide Hard Assets (High) Van Kampen’s UIF Emerging Markets Equity Portfolio – Class I (Highest) Van Kampen’s UIF U.S. Real Estate Portfolio – Class l (High)

Total

146

$

147

$

123

$

127

$

118

$

212

$

$

*Premiums or transfers will not be accepted into this Investment Division on o r after 6/1/2007 if you did not have Cash Value in this Investment Division prior to 6/1/2007. If you remove all Cash Value from this Investment Division on or after 6/1/2007, you will not be allowed to reinvest in this Investment Division. **Formerly Janus Aspen Series Worldwide Growth.

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SECTION E

INCOME TAX WITHHOLDING ELECTION

A partial withdrawal may result in a taxable gain reportable to the IRS on IRS Form 1099. In addition, a 10% penalty tax may be imposed if you make a withdrawal from your life insurance policy that is a modified endowment contract and you are not disabled or you receive your distributions before you are age 59½. The withdrawals you receive are subject to federal income tax withholding unless you elect not to have federal income tax withheld from the withdrawal. Please read the Important Tax Information on page 7 before you select a withholding election. You should consider very carefully which box you check. You should consult with your personal tax advisor, plan administrator, State income tax authority, or your local IRS office if you have any questions about income tax withholding. IRS publication 505 (Tax Withholding and Estimated Tax) and IRS form W-9 may also be helpful. Please provide us with your Taxpayer Identification Number (TIN).

1.____________________________________ Taxpayer Identification Number Are you a citizen of the United States?

Yes

No

2._____________________________________ Taxpayer Identification Number Are you a citizen of the United States?

Yes

No

PLEASE INDICATE YOUR WITHHOLDING ELECTION BY CHECKING THE APPROPRIATE BOX BELOW: I elect to have the following withholding option applied to this payment and any future payments under this policy (please check only one box). Please Note: Non-natural owners (companies, corporations) cannot elect to have no withholding apply.

No Withholding: I elect to have no Federal or State Income taxes withheld from this payment and from any future payments under this policy.

Federal Withholding Only: I elect to have Federal Income taxes withheld from this payment and from any future payment. No State income taxes will be withheld. (This option may not be available for residents of certain states. See the State Income Tax Withholding section of this form.)

Both Federal and State Withholding: I elect to have both Federal and State income taxes withheld from this payment and from any future payments under this policy.

State Withholding Only: I elect to have State income taxes withheld from this payment and from any future payment. No Federal income taxes will be withheld.

If you elected any of the options above in which taxes will be withheld, you can specify the tax withholding percentage (%) of each withdrawal you would like to have applied to Federal and/or state income tax withholding. If a specific tax withholding amount is not indicated below, we will withhold 10% for federal tax purposes and the state’s minimum withholding (if applicable). Please fill in items (1) and (2). (1) I would like to apply _______% of the taxable portion to Federal Withholding. (2) I would like to apply _______% of the taxable portion to State Withholding. If you elect to have Federal income tax withheld, we are required to withhold at least 10% of the taxable portion of the distribution. If your state requires withholding, we will withhold the state’s minimum amount if you select an amount that is less than the minimum. Please see the Important State Income Tax Withholding Information on page 8 for more information.

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SECTION F

AUTHORIZATION AND SIGNATURES

I, the policyowner, understand and agree that: • Partial Withdrawals may reduce the death benefit payable under the policy. • Distributions that are taxable will be reported to the IRS on Form 1099R. • It is the participant’s responsibility to meet the IRS requirements that qualify for this distribution. • The effective date of this request will be the date it is received in the Variable Products Service Center of New York Life Insurance and Annuity Corporation, completed with all required information for processing. See the instructions on page 1 for this address. • Once the withdrawal is processed, NYLIAC is not obligated to accept any return of the monies distributed. • Distributions that are paying a premium on another New York Life or Long Term Care policy number(s) will be sent directly to the administrator of the policy number(s). Even if you already completed Section C for EFT, please confirm your current address below: _________________________________________________ _________________________________________________ _________________________________________________

If you did not complete Section C for EFT, please check here:

Please send my check to the address of record.

Please Note: All signatories must provide their Taxpayer Identification Number in the Income Tax Withholding Election section on page 4. 1.) Policyowner(s) Signature X ______________________________________________ Date _______________ 2.) Assignee or X___________________________________________________________ Date _______________ Other Required Signature Policyowner(s) phone number (9am - 5pm eastern time) (

)____________________________

If the indicated policy is corporate-owned, provide signatures and titles of two corporate officers. 3.) Signature of Officer X __________________________________________________ Date ________________ Officer’s Title ___________________________________________________________ 4.) Signature of Officer X __________________________________________________ Date ________________ Officer’s Title ___________________________________________________________

FILE WITH APPLICATION

Office Received Stamp

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IMPORTANT STATE INCOME TAX WITHHOLDING INFORMATION In addition to the Federal income tax withholding requirements, some states require withholding on policy gains when federal income tax is withheld. As of January 1, 2008, the following states require state income tax withholding when federal income tax withholding is in effect: Iowa, Kansas, Maine, Maryland, Massachusetts, Nebraska, Oklahoma, Vermont, and Virginia. If you live in Arkansas, California, Delaware, Georgia, North Carolina, or Oregon, we are required to withhold state income tax if federal income tax withholding is in effect, unless you elect not to have state income tax withheld. Certain exceptions and special rules apply in some states. For more information regarding the withholding requirements applicable in your state, please consult your tax advisor or state tax authority. If you reside in any of the following states and request state tax withholding, you must also specify the percentage of state tax withholding that you choose to apply to the taxable portion of the withdrawal: Alabama, Arizona, Colorado, Connecticut, District of Columbia, Idaho, Illinois, Indiana, Kentucky, Louisiana, Michigan, Minnesota, Missouri, Montana, New Jersey, New Mexico, New York, North Dakota, Ohio, South Carolina, Utah, West Virginia, and Wisconsin. If a percentage is not specified, state tax will not be withheld.

IMPORTANT FEDERAL INCOME TAX WITHHOLDING INFORMATION This information is required to carry out the Internal Revenue laws of the United States and to provide you with some basic information about withholding of Federal income tax from your payment under the policy specified on the front of this form. A partial withdrawal may result in a taxable gain reportable to the IRS. Generally, Federal withholding applies to payments made from pension, profit-sharing, stock bonus, annuity and other employee deferred compensation plans, individual retirement arrangements (IRA), tax-sheltered annuities (TSA), and commercial annuities (which include individual annuity, life insurance and endowment policies). Federal income tax may be withheld only from the taxable portion of your payment (as determined from our records) at a flat 10% rate. Federal income tax must be withheld unless you elect not to have withholding apply to the taxable portion of your payment. You can make this election by checking the appropriate box in Section E, the INCOME TAX WITHHOLDING ELECTION section. Generally, your election as to whether taxes are or are not to be withheld will apply to any other payment from the same policy. You may change this election at any time. To change your previous election, check one of the boxes in Section E, the INCOME TAX WITHHOLDING ELECTION section. Even if you elect not to have Federal income tax withheld, you are liable for the payment(s) of such tax on the taxable portion of your payment(s). There are penalties under the estimated tax payment rules if enough tax has not been paid through either estimated tax payments or withholding. There is an additional 10% penalty tax imposed by the IRS on “premature distributions” from annuity contracts and modified endowment contracts, unless you are disabled or at least 59½ years of age at the time the withdrawal is made. If the taxable portion of a payment when added to the taxable portion of all other payments during the year is less than $200, Federal income tax is not required to be withheld. We will not withhold Federal income tax if the payment is being made to the Trustees of a qualified pension or profit sharing plan.

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